WASHINGTON -- Briana Scurry couldn't be sure if it was the painkillers or the fact that surgeons had just plucked pea-size balls of damaged tissue from the back of her head. But when the two-time Olympic goalkeeper and Women's World Cup champion awoke at MedStar Georgetown University Hospital in Washington on Oct. 18, the headache that had hijacked her life for the past 3½ years was gone.
Since an April 2010 game, when an overeager forward slammed into Scurry, that headache chased her from one defeat to another: forcing her to quietly retire from soccer, tripping her up during a short-lived gig with ESPN and finally pushing her into depression.
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Her roommate would come home from work and find Scurry listless on the couch, where she'd been all afternoon.
On those days, Scurry found herself beset with questions familiar to many athletes who suffer serious concussions: What is wrong with me? And why am I not better yet?
Scientists can't entirely answer those questions, but a growing body of research suggests that -- counter to the popular imagery of young men smashing into each other in football and hockey -- female athletes suffer relatively more concussions than their male counterparts, and they struggle with more dramatic symptoms when they do.
In high school sports that have similar rules for boys and girls, girls get concussions at twice the rate, according to a 2011 study in the American Journal of Sports Medicine. Another study found that among all collegiate athletes, female soccer players had the highest overall concussion rates.
Even as she came up from the haze of anesthesia, Scurry could mumble one estimate to a curious hospital employee: About one in two female soccer players will get a concussion in her career.
Scurry has become something of an expert on concussions. For her, the biggest problem was always the headache, a relic of the damage done to her neck and occipital nerve when the blow to her temple snapped her head back.
Neck damage occasionally accompanies serious concussions, says Kevin Crutchfield, the neurologist Scurry turned to in February. Many clinicians respond with prescriptions for drugs such as Vicodin.
But Crutchfield, in collaboration with MedStar Georgetown peripheral nerve surgeon Ivica Ducic, has pioneered a new approach to post-concussion recovery: occipital nerve release surgery, a procedure common for patients who suffer migraines and chronic headaches.
The occipital nerve -- a slimy, five-millimeter cord that runs up from the spine and fans across the back of the head -- tunnels through muscles that can pinch it and cause pain.
It was the persistent pain that felled Scurry, 42, a slim, no-nonsense jock known for her on-field glower and intensity.
The crowning moment of her career -- a shootout save in the 1999 World Cup final against China -- was a dramatic, across-the-goal dive memorialized on sports pages around the world. Scurry yelled and fist-pumped afterward, but she didn't really smile.
Then again, maybe Scurry had simply grown accustomed to success. A native of Dayton, Minn. -- "3,000 people, no stoplights," she says -- she tried out for the local boys' soccer team at age 12. She wound up in the net only because that's where her coach assumed a girl would feel safest. But Scurry's father, Ernest, told his daughter -- the baby of the family and the youngest, by nine years, of nine children -- to play hard and "always be first," whether in line at the bus stop or at the Olympics. She listened.
She went on to play varsity soccer, basketball, softball and track for the Anoka High School Tornadoes, deciding to continue with soccer only when the University of Massachusetts at Amherst made it clear that it was the best route to an athletic scholarship. She majored in political science with the vague plan of someday attending law school.
But in 1994, before she finished her undergraduate degree, Scurry got a call from Tony DiCicco, coach of the women's national soccer team, who had heard good things about the U-Mass. Minutewomen's goalie.
She started in the 1995 Women's World Cup, where the United States placed third, and won gold at the 1996 Olympics, allowing only three goals during the five-game tournament.
But women's soccer didn't make many magazine covers or prime-time newscasts until 1999, when Scurry and the rest of the U.S. national team packed the Rose Bowl with a record 90,000 fans and beat China in an overtime shootout for the World Cup. History would remember Brandi Chastain's shirtless celebration at the top of the penalty box, but Scurry's save three minutes earlier made that possible.
"Briana Scurry at her peak -- no one has ever played better than that for the USA," said DiCicco, who coached Scurry for five years on the women's national team. "She was the best in the world. That's the truth."
Scurry's career got rocky after the World Cup. In the months that followed, she spent too much time appearing on talk shows and too little time at the gym, gaining 15 pounds and falling so far out of shape that April Heinrichs, who was then the coach of the national team, sidelined her in favor of newcomer Siri Mullinix. Scurry played not a minute in the 2000 Olympic Games.
"I was so incredibly bitter. I felt betrayed," Scurry said in an interview last month at the apartment she recently began renting in Washington. "There was no way I was going out like that, not if I had anything to say about it."
Scurry hit the weight room -- and put on 10 pounds of muscle. She played three seasons for Atlanta's professional team, the Beat, compiling the lowest goals-against average in the league. In 2002, two years after Mullinix unseated her, Heinrichs returned Scurry to the starting lineup. The United States went on to win gold in Athens in 2004.
She would always need to fight for her starting spot, however, first against Mullinix and then against the fresh-faced media favorite Hope Solo. During the 2007 World Cup semifinals, when Scurry gave up four goals to give Brazil the win, fans called for Scurry and her coach to retire.
But even before the rivalries, goalkeeping was intensely psychological for Scurry. After all, a professional soccer net offers almost 200 square feet of scoring opportunities. Missed saves are inevitable, and rarely forgiven.
To cope with this, Scurry gave herself a rigid mental rule: You have the time between the goal you just allowed and the start of the next play to sulk. When the whistle blows, you forget that anything bad ever happened.
That strategy served her well -- until April 2010.
The hit happened during her second season on the Washington Freedom, D.C.'s defunct professional team. She had warmed up as usual for an away game against the Philadelphia Independence, diving and falling for balls thrown by her trainer and listening to the mix of Eminem and Nine Inch Nails that always got her pumped for play.
The game started, then lagged, as the ball ping-ponged around the center of the field. Then, with 10 minutes left in the first half, a ball finally skidded toward Scurry and she dropped low for a routine grab.
She didn't see the 165-pound, fast-charging forward from the Philadelphia Independence before her knee slammed into Scurry's right temple, leaving them both on the turf.
"'Let's go, keep,'" Scurry remembers the referee saying, urging her to get up. She had, miraculously, blocked the shot. " 'You're all right, keep.' "
Scurry played for several minutes after the collision, even saving a few more balls, as the world began to tip up at odd angles and the numbers on her teammates' jerseys zoomed in and out of focus.
Anxious that she might throw up, Scurry stumbled to the sideline and down to the locker room, where she couldn't repeat the string of words a trainer read her to test for brain trauma.
Doctors initially estimated that she'd need a few days to recover, as most people who suffer concussions do. When her symptoms persisted, they revised that estimate to two weeks. Then 60 days. Then indefinitely. Her career was over.
She struggled with post-concussive symptoms: poor balance, memory loss, insomnia that only Ambien could overcome. Her headaches demanded a muscle relaxant, a prescription painkiller and daily afternoon naps.
She came to organize her life around naps and walks, first around the park near her apartment in Englishtown, N.J., and then in Washington, where she moved to be closer to her doctors. The walks became the only highlights in a lonely, unchanging schedule otherwise ruled by watching ESPN and back seasons of "Dexter" and "Breaking Bad."
In the days leading up to her surgery, Scurry cued up Deepak Chopra's "How to Know God" on audiobook, shouldered her favorite black Puma backpack and set off on a geriatric-paced three-mile stroll. The Lululemon types who flew past her with little more than an "On your left!" could never have guessed this woman had won two Olympic gold medals.
Even more disturbing than her other symptoms was this: Scurry -- whose World Cup teammates had called her "The Wall" and joked about her grim, pregame focus -- became spacey, anxious and depressed. Her former roommate Naomi Gonzalez, who met Scurry as the massage therapist for the Freedom, watched her friend fall silent during the televised Chelsea games she had loved to scream at before.
There were long months when Scurry didn't believe that her old self would ever return, when she feared that her symptoms would never end.
An injury to the brain is not like an injury to the knee, with clear causes and effects and formulas for treatment. Because the brain is so complex and so little understood, each patient's case is different.
"Concussions fight dirty," said Michael Collins, the executive director of the Sports Medicine Concussion Program at the University of Pittsburgh Medical Center. "They're very heterogenous: Anyone who thinks 'a concussion' means just one thing is mistaken."
On Oct. 18, her surgeon, Ducic, makes the two-inch incision above Scurry's hairline and begins tweezing bloody connective tissue from around her occipital nerve. He finds that these bits of fascia are tougher and more fibrous than they should be.
"Yes, see," he murmurs to the resident and medical student huddled over Scurry's body. "She was exposed to quite a bit of trauma."
The whole thing takes less than an hour. Among sports concussion patients, the operation eases chronic headaches 90 percent of the time, according to Ducic.
But the surgery has yet to catch on. Ducic has performed it about 100 times for concussion patients, in contrast to the more than 2,000 times he's operated on patients with chronic headaches or migraines.
Collins says doctors and insurers still see surgery as a last-ditch measure, given the many nonsurgical interventions available. (Scurry's surgery was covered by insurance.) Of the 20,000 clients his clinic saw in the past year, he recalls only three even considering it.
Despite the recent surge in concussion awareness, researchers and doctors still know very little about the exact mechanics of concussion. They understand the initial trauma, when the brain bumps up against the skull and begins to bleed or bruise.
Less clear are what Shane Caswell, executive director of George Mason University's sports medicine lab, calls the "effects downstream" -- such things as impaired cognition, memory loss, imbalance, mood disorder and changes to brain physiology.
Researchers also don't entirely understand why women seem to suffer more concussions than men.
The most common theory: Women have smaller and weaker necks, which makes their heads more prone to the violent snapping that results in serious concussions. Estrogen levels and cerebral blood flow, which differ by sex, may also play a role.
Concussions also tend to amplify certain pre-existing conditions, and women experience far higher migraine, anxiety and depression rates than men.
But there's also a serious risk of reporting bias: Perhaps women only appear to get more headaches because women are more comfortable speaking up when they're hurt.
An extensive study released recently by the Institute of Medicine and the National Research Council warns that young athletes in particular face a "culture of resistance" when it comes to reporting and treating concussions.
Whatever the reasons, the numbers are dramatic.
In Caswell's study of high school athletes at Fairfax County (Va.) Public Schools, girls were almost twice as likely to suffer a concussion as boys in sports whose rules and equipment were similar for both sexes.
A study of high school and college athletes in 2007 found that soccer carried the highest concussion risk of any women's sport.
Perhaps most surprisingly, it found that women playing soccer in college suffered concussions at a higher overall rate than athletes in any other sport, including football. Researchers point out that these figures take both games and practices into account, which could skew the concussion rates in sports like soccer where athletes often practice in gamelike conditions.
Statistics indicate that most female soccer players who get concussions do so while heading the ball -- or, more accurately, while heading other players in the attempt.
That finding doesn't surprise Becca Wann, an aggressive 21-year-old forward from the University of Richmond who won gold on the U.S. team at the 2012 under-20 World Cup, then retired in early September after suffering the fifth concussion of her young career. (When Wann thinks back to the number of times she has blacked out or seen rainbows after heading the ball, she suspects she has had more.)
"I'd thought of trying to pursue a professional career, or maybe playing overseas. Now that's gone," she said. "But we don't know what the next concussion will do. I want a life 40 years down the road. There's more to life than soccer."
Wann's is one of several high-profile concussions in the past three months. Emily Oliver, an all-star goalkeeper at Stanford, made a tearful retirement announcement in September after suffering her fourth concussion.
Days earlier, paramedics airlifted a goalkeeper at Niagara University to a hospital after she dived for a ball and collided headfirst with the goal post.
But in the heat of the game, many athletes try to play on after injury. Last spring, Abby Wambach, named professional soccer's 2012 World Player of the Year, got hit by a ball and lay dazed on the turf for several moments while the ref waved her trainer away. Wambach finished the game, but in the furor that followed, the National Women's Soccer League promised to redouble its efforts to educate officials and players on concussion risk.
Local soccer leagues have begun paying attention, much as youth football and lacrosse teams have begun adjusting rules in the wake of those sports' concussion scandals.
The Washington Area Girls' Soccer League, with its 613 teams and 9,195 players, is encouraging coaches and parents to download a smartphone app called "PAR CAR" that details concussion signs and symptoms. It wants coaches to stress proper heading and slide-tackling techniques.
Next year, every player at the league's annual tournament will get a concussion pamphlet, says WAGS spokeswoman Sally D'Italia.
"A large part of this is awareness," said D'Italia, whose daughter plays soccer at the collegiate level. "Life has to go on after soccer."
The league may find an advocate in Scurry, who hopes to reinvent herself as a role model for concussion recovery. She has launched a slick website and begun talking to foundations that work with concussed athletes.
She might go back to school and finish a business degree. The day before her surgery, Scurry and Gonzalez sat side by side at Scurry's small kitchen table, puzzling out the details of a new Facebook page. Within an hour, Scurry had 21 fans.
"I'm excited I'm going to get my friend back," Gonzalez said. "I've been waiting a long time."
"I know," Scurry said quietly. "I've been gone a long time."
This comeback cannot be like her last one, though. Doctors say that, assuming that her headaches do not return, Scurry can begin therapy to address her other symptoms, including imbalance and memory loss.
A little over two weeks after Ducic cut into her head, Scurry's prognosis looks good: Her only lingering head pain comes from the stitches along the back of her head, and feeling has begun to creep back through her scalp. But Scurry will never exercise her way back to the national team. That game, at least, is over.
Recuperating in her apartment, Scurry seems unconcerned. She has already argued with Gonzalez about how soon she could return to running. She's put a photo of her mother and a Post-it note on the fridge. "Health, wealth, love," it reads.
"Of course I was initially down about my injury," Scurry said. "But I decided to turn it around. I asked myself: 'What can I control?' … I never lost hope of that.
"If my lot isn't as big as before, I'm going to do more with the lot I have."